Morbidity and Mortality Weekly Report · 29.09.2002 · Morbidity and Mortality Weekly Report ......

Morbidity and Mortality Weekly Report

Weekly October 18, 2002 / Vol. 51 / No. 41

Centers for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionSAFER • HEALSAFER • HEALSAFER • HEALSAFER • HEALSAFER • HEALTHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETM

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924 Q Fever — California, Georgia, Pennsylvania, andTennessee, 2000–2001

927 Probable Variant Creutzfeldt-Jakob Disease in a U.S.Resident — Florida, 2002

929 West Nile Virus Activity — United States, October 10–16, 2002, and Update on West Nile Virus Infections inRecipients of Blood Transfusions

931 Pneumococcal Vaccination for Cochlear ImplantRecipients

Local Transmission of Plasmodium vivax Malaria — Virginia, 2002Malaria transmission in the United States was largely elimi-

nated during the mid-20th century; however, sporadic casesof locally acquired mosquito-transmitted malaria continueto occur. Since 1997, four separate probable mosquito-transmitted malaria outbreaks have been reported to CDC,including one from Virginia (1–3). This report describes theinvestigation of two cases of Plasmodium vivax malaria thatoccurred in northern Virginia in August 2002, and under-scores the need for clinicians to consider the possibility ofmalaria in patients with fever of unknown origin.

Case ReportsCase 1. On August 23, 2002, a person aged 19 years from

northern Virginia sought medical care at a family health clinicwith a 4-day history of fatigue, fever, and chills. The patientalso complained of muscle aches and sinus pain. A sinusinfection was diagnosed, and the patient was prescribedazithromycin and desloratadine. Four days later, the patientreturned to the clinic with additional symptoms, dizziness,and nausea. On physical examination, the patient had a tem-perature of 103.5º F (39.7º C) and tachycardia. Laboratoryresults revealed pancytopenia (platelet count: 61,000/µL[normal: 130,000–400,000/µL], hemoglobin: 10 g/dL [nor-mal: 11.5–16.0 g/dL], and white blood cell count: 3,300/µL[normal: 4,000–11,000/µL]). The patient’s therapy waschanged to oral levofloxacin. Malaria parasites were identi-fied subsequently on a routine complete blood count smeartaken 4 days after the initial clinic visit. The patient was con-tacted and administered chloroquine. A review of the initialmalaria smear by a local university hospital confirmed thediagnosis of P. vivax malaria. The patient completed a 3-daycourse of chloroquine therapy and after a normal glucose-6-phosphate dehydrogenase (G6PD) test result was placed onprimaquine for 14 days. The patient had complete resolutionof symptoms.

Case 2. On August 25, a person aged 15 years from north-ern Virginia was taken to a local emergency department fortreatment of 2 weeks of headaches and 4 days of fever, nausea,vomiting, malaise, and nose bleeds. On physical examination,the patient had a temperature of 105.0º F (40.6º C), tachy-cardia, splenomegaly, and jaundice. Laboratory values revealedpancytopenia (platelet count: 48,000/µL, hemoglobin: 11.6g/dL, and white blood cell count: 3,200/µL). A malaria smearrevealed Plasmodium sp. parasites reported initially asnonfalciparum. The patient was admitted to the hospital andadministered quinine and clindamycin. The smear was con-firmed subsequently as P. vivax by the Virginia Departmentof Health. The patient’s physician contacted CDC for treat-ment recommendations on August 28 because the patient hadtinnitus, requiring discontinuation of the quinine. Thepatient completed a 3-day course of chloroquine therapy andwas discharged with complete resolution of symptoms onAugust 31. After a normal G6PD test result, the patient wasplaced on primaquine for 14 days.

Epidemiologic InvestigationThe two patients had no risk factors for malaria, including

international travel, blood transfusion, organ transplantation,

922 MMWR October 18, 2002

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Editor, MMWR Series

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Notifiable Disease Morbidity and 122 Cities Mortality DataRobert F. Fagan

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or needle sharing. The patients lived approximately 0.5 milesapart; however, the 19-year-old patient reported numerousvisits to friends who lived directly across the street from the15-year-old patient. Residents in the neighborhood surround-ing the patients’ homes were asked about recent febrile ill-nesses. Medical records from two hospitals serving residentsin the patients’ neighborhood also were reviewed, and chartsof patients with a diagnosis of fever of unknown origin wereobtained. None of the patients’ neighbors had unexplainedfebrile illnesses. Of 224 hospital records available for review,21 documented fever with no underlying cause. One of the21 patients had persistent symptoms; however, a malaria smeardid not reveal malaria parasites. No further cases of locallyacquired malaria have been reported in northern Virginia.

Washington Dulles International Airport is located <10miles from the patients’ homes. The airport receives nonstopinternational flights from countries in which P. vivax malariais endemic. Ill travelers are sent to one of the hospitalsincluded in the investigation’s case-detection activities. Phy-sicians at two Army bases located nearby were contacted andreported no known cases of malaria or fever of unknown originin troops returning from areas in which malaria is endemic.

Environmental and EntomologicInvestigation

The patients’ homes were visited. One home had severalunscreened or poorly screened windows; the other had well-screened windows and a porch. Within the vicinity of bothhomes was a wooded area with a creek and ponds. As a part ofongoing West Nile virus (WNV) surveillance activities, trap-ping for anopheline mosquitoes within 10 miles of thepatients’ homes yielded Anopheles quadrimaculatus andAn. punctipennis (Figure). Of approximately 870 anophelinemosquitoes tested, five pools (four to six mosquitoes per pool)captured within 2–6 miles of the patients’ homes tested posi-tive for P. vivax-210 circumsporozoite protein by using a fieldtest (VecTest™ [Medical Analysis Systems, Inc., Camarillo,California]) on September 25 and 27 and October 1, 6, and11. No mosquito pool has tested positive repeatedly in con-firmatory testing by using polymerase chain reaction (PCR);however, efforts to confirm the positive VecTest™ mosquitopools are ongoing.Reported by: A Pastor, MD, Loudoun Healthcare Dept of InfectiousDiseases; J Neely, Clarke Environmental Mosquito Management;D Goodfriend, MD, Loudoun County Dept of Health, Leesburg; J Marr,MD, S Jenkins, VMD, D Woolard, PhD, D Pettit, PhD, D Gaines,PhD, D Sockwell, MSPH, Virginia Dept of Health. C Garvey, MD,C Jordan, C Lacey, Montgomery County Health Svcs, Rockville;T DuVernoy, DVM, Maryland Dept of Health and Mental Hygiene.D Roberts, PhD, L Robert, PhD, P Santos, Div of Tropical Public Health,

Vol. 51 / No. 41 MMWR 923

Uniformed Svcs, Univ of theHealth Sciences, Bethesda,Maryland. R Wirtz, PhD,J MacArthur, MD, Div ofParasitic Diseases; M O’Brien,Div of Applied Public HealthTraining, Epidemiology ProgramOffice; L Causer, MBBS, EISOfficer, CDC.

Editorial Note: Despitemalaria eradication certifi-cation in the United Statesin 1970 (4,5), 10 outbreaksinvolving 17 cases ofprobable locally acquiredmosquito-borne malariatransmission have occurredsince 1992 (1). The twocases from northernVirginia represent the firstcases of probable mosquito-borne malaria transmissionin the United States since1999 (1,2) and the secondreported outbreak in

Virginia (3). These outbreaks share common features: 1) aninitial case without known risk factors for malaria, 2) prob-able proximity to a person with malaria parasitemia, 3) pres-ence of competent mosquito vectors, and 4) environmentalconditions conducive to the maturation of the parasite in themosquito.

Approximately 1,000–1,500 cases of malaria in the UnitedStates are reported annually to CDC (6). The majority arediagnosed in travelers from countries in which malaria isendemic. The source of infection in the two northern Vir-ginia residents was probably the bite of an infective mosquitothat had acquired the parasite by biting a malaria-infectedperson in the general vicinity. Several Anopheles sp. mosqui-toes native to the United States are competent malaria vec-tors. The An. quadrimaculatus and An. punctipennismosquitoes captured near the patients’ homes have beenimplicated in previous cases of locally acquired malaria (2,3).Numerous pools of these vectors were tested by usingVecTest™. Although this test is used commonly in interna-tional settings (7), this is the first time the test has been usedin an investigation of mosquito-borne malaria in the UnitedStates. The identification of five malaria-positive pools amongapproximately 870 tested mosquitoes is unexpectedly highand has not been observed previously during an investigation

of a malaria outbreak in the United States. Rapid screeningtests such as the VecTest™ were not available previously. How-ever, because VecTest™ is a new tool for the investigation oflocal mosquito-borne malaria in the United States, its validityin this setting is unknown, and results need to be confirmedby using PCR. Efforts are under way to develop testing algo-rithms for screening mosquito pools by using VecTest™ andconfirming results with PCR.

This investigation underscores the need for clinicians toconsider the possibility of malaria in patients with fever ofunknown origin. Although a thorough travel history and risk-factor assessment should be a part of the evaluation of febrilepatients, the possibility of malaria in patients without inter-national travel, blood transfusion, organ transplantation, orneedle sharing should be considered. Rapid diagnosis andtreatment with effective antimalarial drugs are the basis ofpatient case management and will reduce the chances that aninfected host will transmit the parasite. The same precautionsrecommended for minimizing exposure to WNV should befollowed for reducing exposure to malaria-infected Anophelessp. mosquitoes, including wearing long-sleeved shirts and longtrousers, using insect repellent containing N,N-diethylm-toluamide (DEET), and avoiding outdoor activities duringthe late evening. Prompt reporting of patients withmalaria to local public health authorities assists in activatingcontrol measures for these isolated cases of mosquito-bornemalaria.

AcknowledgmentsThis report is based on data contributed by L Frank, R Helfrich,

Montgomery County Health Svcs, Rockville; C Lesser, MarylandDept of Agriculture; D Blythe, MD, Maryland Dept of Health andMental Hygiene.

References1. MacArthur JR, Holtz TH, Jenkins J, et al. Probable locally acquired

mosquito-transmitted malaria in Georgia, 1999. Clin Infect Dis2001;32:E124–E128.

2. CDC. Probable locally acquired mosquito-transmitted Plasmodium vivaxinfection—Suffolk County, New York, 1999. MMWR 2000;49:495–8.

3. Strickman D, Gaffigan T, Wirtz RA, et al. Mosquito collections follow-ing local transmission of Plasmodium falciparum malaria in WestmorelandCounty, Virginia. J Am Mosq Control Assoc 2000;16:219–22.

4. Bradley G. A review of malaria control and eradication in the UnitedStates. Mosquito News 1966;26:462–70.

5. Wernsdorfer WH, McGregor I. Malaria: Principles and Practice ofMalariology. Edinburgh, New York: Churchill Livingstone, 1988.

6. Causer LM, Newman RD, Barber AM, et al. Malaria surveillance—United States, 2000. In: CDC surveillance summaries (July 12). MMWR2002;51(No. SS-5):9–23.

7. Ryan JR, Dave K, Collins KM, et al. Extensive multiple test centreevaluation of the VecTest malaria antigen panel assay. Med Vet Entomol2002;16:321–7.

FIGURE. CDC light trap usedduring investigation to captureAnopheles sp. mosquitoes

Photo/CDC


* Confirmed Q fever: A clinically compatible case that is laboratory confirmedwith one of the following: 1) a fourfold change in antibody tier to C. burnetiiantigen by immunofluoresence antibody assay or complement fixation antibodytest, 2) a positive polymerase chain reaction assay, 3) culture of C. burnetiifrom a clinical specimen, or 4) positive immunostaining of C. burnetii in tissue.Probable Q fever: a clinically compatible case with single supportive IgG ofIgM titer as defined by the testing laboratory.

Q Fever — California, Georgia,Pennsylvania, and Tennessee,

2000–2001Q fever is a zoonotic disease caused by the bacterium

Coxiella burnetii. The most common reservoirs are domesti-cated ruminants, primarily cattle, sheep, and goats. Humansacquire Q fever typically by inhaling aerosols or contaminateddusts derived from infected animals or animal products. Itshighly infectious nature and aerosol route of transmissionmake C. burnetii a possible agent of bioterrorism (1). Althoughup to 60% of initial infections are asymptomatic (2), acutedisease can manifest as a relatively mild, self-limited febrileillness, or more moderately severe disease characterized byhepatitis or pneumonia. It manifests less commonly as myo-carditis, pericarditis, and meningoencephalitis. ChronicQ fever occurs in <1% of infected patients, months or yearsafter initial infection. Chronic disease manifests most com-monly as a culture-negative endocarditis in patients with val-vular heart disease. During 2000–2001, a total of 48 patientswho met the case definition* of Q fever were reported to CDC.This report describes the case investigations for six of thesepatients, which indicate that these persons acquired Q feverprobably through direct or indirect contact with livestock.To enhance surveillance efforts, health-care providers shouldreport cases of Q fever to state health departments.

CaliforniaIn May 2001, a woman aged 56 years sought treatment

from her health-care provider for fever (104º F [40º C]),hepatomegaly, and elevated liver enzymes (alkaline phos-phatase 532 U/L [normal: 30–100 U/L], SGOT 178 U/L[normal: 9–25 U/L], and SGPT 149 U/L [normal: 7–30 U/L]).Acute cholecystitis was diagnosed, and a cholecystectomy wasperformed. After the procedure, the patient’s symptoms per-sisted, and she developed pain and partial paralysis of the leftleg. Approximately 4 weeks after the woman sought treat-ment initially, a computed tomography (CT) scan of thepatient’s chest revealed nonspecific interstitial lung disease.Serum samples obtained near the time of the CT scan and6 weeks later were tested by an indirect immunofluoresenceantibody (IFA) assay and demonstrated IgG antibodies reac-tive with C. burnetii phase II antigens at reciprocal titers of

>1,024, confirming a diagnosis of Q fever. The patient’s hus-band aged 62 years also developed a nonspecific febrile illness3 days after the onset of his wife’s illness; serum specimensobtained from him in June and July and tested by IFA dem-onstrated IgG antibodies reactive with C. burnetii phase IIantigens at reciprocal titers of >1,024. Canvassing of the neigh-borhood by a public health nurse revealed that a next-doorneighbor aged 76 years had a nonspecific febrile illness inApril 2001. His serum was obtained in August and Octoberand was tested by IFA; both specimens demonstrated IgGantibodies to C. burnetii phase II antigens at reciprocal titersof >1,024. The three patients were treated with doxycycline;their symptoms resolved, but the woman has residual neuro-logic deficits in her left leg.

The couple did not own livestock but drove daily on anunpaved road past a neighbor’s goat herd. Goat kids had beenborn at the farm during the spring. Serum specimens obtainedfrom 48 goats in this herd were tested by CDC by using IFA;45 (94%) animals had IgG antibodies to C. burnetii at recip-rocal titers indicative of current or previous infection (titerrange: 32–16,384).

GeorgiaIn March 2001, a man aged 46 years sought treatment for

acute onset of fever, chills, cough, and weight loss; influenzawas diagnosed. The patient’s symptoms persisted, and after2 weeks he sought further treatment at an emergency depart-ment, where influenza again was diagnosed, and he wasreferred to an infectious disease specialist. A serum samplewas tested by IFA and reacted with C. burnetii phase II anti-gens at a reciprocal titer of >256. The patient was adminis-tered a 5-day course of the fluoroquinolone gatifloxacin, andsymptoms resolved within 2 weeks. A convalescent-phaseserum sample obtained in April and tested by IFA demon-strated an IgG reciprocal antibody titer reactive withC. burnetii phase II antigens of >16,384.

The patient owned several dairy cows, but there had beenno recent animal births on the premises. Two beef cattle herdsof approximately 35 animals each were pastured across theroad from the patient’s farm. Serum was drawn from 14 cattlefrom these herds; two animals tested by IFA reacted with phaseI or II antigens of C. burnetii at reciprocal antibody titers(16–32).

PennsylvaniaIn September 2000, a man aged 90 years sought treatment

for fever (101.0º F [38.3º C]) and a 4-month history of mal-aise and weight loss after a cholecystectomy. The patient hadelevated liver enzymes (alkaline phosphatase 181 U/L

Vol. 51 / No. 41 MMWR 925

[normal: 45–115 U/L] and SGOT 51 U/L [normal: 1–40U/L]). He was admitted to the hospital for diagnostic evalu-ation. In 1998, the patient had undergone aortic valvereplacement for culture-negative endocarditis and valvularinsufficiency. A serum sample drawn in November 2000 wastested by IFA and demonstrated IgG antibodies reactive withC. burnetii phase I antigens at a reciprocal titer of >524,288.Presence of C. burnetii was demonstrated in the excised aor-tic heart valve tissue from 1998 when tested by immunohis-tochemical (IHC) staining at CDC. The patient was startedon long-term doxycycline therapy in October 2000. Sinceelecting to discontinue this therapy 1 year later, the patienthas had two recurrences. He was admitted to the hospital inSeptember 2002 for fever and hypotension.

The patient had owned and operated a cattle farm but hadretired from farming 30 years previously. The patient’s rela-tives raised sheep and goats nearby, but the patient deniedhaving contact with their animals. One relative, who raisedsheep, was found to have an antibody titer reactive withC. burnetii phase I antigens but had not experienced illness.

TennesseeIn February 2001, a man aged 49 years was admitted to a

hospital with a right lower-extremity embolism. The patientreported a 6-month history of intermittent fever, night sweats,fatigue, and arthralgias. A heart murmur had been diagnosed4 months previously. On admission, he had a temperature of99.2º F (37.3º C) and leukocytosis (white blood cell count of14.3x109/L [normal: 4.5–11.0x109/L]). The embolism in hisleg was removed surgically. An echocardiogram after hospitaladmission revealed a bicuspid aortic valve with moderatestenosis and severe regurgitation, and aortic valve replacementwas performed. Microscopic examination of the excised valverevealed a vegetative growth, but no bacteria or fungi weredetected by histopathology or routine cultures. Serumobtained 1 week after admission was tested by IFA and dem-onstrated IgG antibodies reactive with C. burnetii phase Iantigens at a reciprocal titer of >512, and the patient wasadministered doxycycline and levofloxacin. CDC detectedDNA of C. burnetii in the excised aortic valve by polymerasechain reaction (PCR). The embolus removed from the patient’sright leg tested positive for C. burnetii by IHC staining. Thepatient was discharged but was readmitted 10 days later forpericardial effusion with tamponade, which resolved aftersurgical intervention.

The patient owned one goat and a herd of approximately100 cattle. In February 2000, the patient had been present atthe stillbirth of one calf and the premature delivery and deathof a second calf. Serum samples from 24 cattle in his herd

were collected in July and tested for antibodies to C. burnetiiby IFA; one animal had reactivity to phase I and II antigens ata reciprocal titer of 16.Reported by: M Jay-Russell, DVM, California Dept of Health Svcs;J Douglas, Calaveras County Dept of Health, San Andreas, California.C Drenzek, DVM, Georgia Div of Public Health, Dept of HumanResources. J Stone, MD, Cumberland; D Blythe, MD, Maryland Deptof Health. A Weltman, MD, Pennsylvania Dept of Health. T Jones,MD, A Craig, MD, Tennessee Dept of Health. J McQuiston, DVM,C Paddock, MD, W Nicholson, PhD, HA Thompson, PhD, Div ofViral and Rickettsial Diseases; S Zaki, MD, National Center forInfectious Diseases; J Wright, DVM, M O’Reilly, MD, D Kirschke, MD,EIS officers, CDC.

Editorial Note: These cases demonstrate acute and chronicclinical characteristics of Q fever and indicate some of therisk factors for acquiring this disease (see box). The bacte-rium C. burnetii is distributed widely in the United States,and human cases of Q fever have been reported from almostevery state (3). Human infections are associated commonlywith exposure to infected animals giving birth, especiallyruminants such as sheep, cattle, and goats. Cats, dogs, wild-life, and birds also are associated occasionally with humaninfection (3,4). Transmission to humans usually occurs byinhalation of droplets or windborne dust containingC. burnetii (2–4). The persons whose cases are described inthis report acquired Q fever probably through exposure toinfected livestock. Most of the six patients had occupationalcontact with livestock (e.g., farming); however, some of thesecases demonstrate that persons need not work in a high-riskenvironment or have direct animal contact to become infectedwith C. burnetii.

In humans, the clinical presentation of Q fever varies widely.Acute Q fever might be characterized by a nonspecific febrileillness, hepatitis, or pneumonia (5). Acute cholecystitis is notknown to be associated with C. burnetii infection; however,the liver manifestations observed in some patients mightresemble gall bladder disease. Although one person describedin this report had a peripheral neuropathy after acute infec-tion, such symptoms are uncommon (6). Chronic Q fevermight manifest months to years after initial infection, mostcommonly as a culture-negative endocarditis (7–9). Personswith underlying heart valve defects or prosthetic valves are atincreased risk for chronic Q fever endocarditis, which mightoccur in up to 40% of persons with valvular heart diseasefollowing acute Q fever (9). Health-care providers should beaware of the signs and symptoms of the disease and considerlaboratory testing for Q fever in patients exhibiting prolongedfever, hepatitis, atypical pneumonia, or blood culture–negative endocarditis, particularly patients whose historiessuggest contact with or exposure to sheep, goats, or cattle.


Q fever usually is diagnosed by evaluating pairedacute- and convalescent-phase serum samples. Inhumans, the antibody response is directed against phaseI and phase II antigens of C. burnetii. Patients with acuteQ fever typically produce an antibody response prima-rily to C. burnetii phase II antigen; chronic C. burnetiiinfections typically elicit a higher antibody response tophase I antigens (10). A diagnosis of Q fever also can beconfirmed by examining biopsies of affected organs byusing PCR or IHC. Serologic tests may be conductedat commercial laboratories, several state health labora-tories, or CDC. In animals, serologic tests for anti-bodies to C. burnetii are more difficult to interpret.Presence of antibodies might indicate previous infec-tion with the organism but cannot be used to predicthuman risk (3).

For treatment of acute Q fever, doxycycline is the drugof choice. Initiation of therapy is warranted in patientswith disease demonstrating clinical and epidemiologicfeatures compatible with Q fever. Because antibiotictreatment is most effective during the early phase of theillness, treatment should not be withheld pendingresults of confirmatory laboratory antibody tests, whichprovide a retrospective diagnosis (2). For patients withpre-existing valvular disease, progression of acute dis-ease to endocarditis is best prevented by combinationlong-term therapy with doxycycline andhydroxychloroquine. This regimen also is recommendedfor patients with active Q fever endocarditis (2,9). Ifthe infection does not resolve with antibiotic therapy,the patient might require excision and replacement ofthe damaged heart valve; however, this will not neces-sarily ensure elimination of C. burnetii, and the newvalve might fail if appropriate antimicrobial treatmentis not initiated or is withdrawn prematurely (5).

Because its highly infectious nature and aerosol routeof transmission make C. burnetii a potential agent ofbioterrorism, human Q fever became a nationally noti-fiable disease in 1999. State health departments shouldreport cases to CDC through the National ElectronicTelecommunications System for Surveillance (NETSS)via event code 10255; to facilitate case reporting,Q fever case report forms are available at http://www.cdc.gov/ncidod/dvrd/qfever/case_rep_fm.pdf.Additional information about Q fever is available athttp://www.cdc.gov/ncidod/dvrd/qfever.

BOX. Epidemiology, diagnosis, treatment, and prevention of Q fever

Epidemiology• Classified as a zoonotic disease• Contracted through exposure to infected ruminants (espe-

cially parturient goats, sheep, and cattle), with incubationtime of 3–30 days

• Distributed broadly throughout the United States• Transmitted primarily through inhalation of airborne bacteria• Highly infectious• Designated a possible bioterrorism agent

Clinical findings• Up to 60% of infections are asymptomatic• Acute disease is characterized most frequently by

— High fever and headache— Pneumonia or hepatitis in approximately 60% of acutely

ill persons— Infrequent acute manifestations including pericarditis,

myocarditis, or meningoencephalitis• Chronic disease occurs in <1% of infected patients

— Occurs predominantly in patients with underlyingvalvular heart disease, vascular aneurysms, or vascular grafts

— Manifests primarily as culture-negative endocarditis, lesscommonly as vascular or osteoarticular infection

Laboratory testing• Diagnosis made by

— Demonstration of fourfold or greater changes in IgG orIgM class-specific testing of paired acute- and convalescent-phase serum samples by immunofluoresence antibody

— Elevated antibody response to C. burnetii phase I or IIantigens

— Detection of C. burnetii by polymerase chain reactionor immunohistochemical staining

Treatment• Acute disease

— Doxycycline 200 mg/day for 2–3 weeks• Acute disease in patients with valvular heart disease

— Doxycycline 200 mg/day plus hydroxychloroquine 600mg/day, for 1 year; dosage of hydroxychloroquineadjusted to maintain plasma level at 1± 0.2 µg/ml

• Chronic— Doxycycline and hydroxychloroquine, dosage as above,

for 1.5–3 years; cessation of therapy determined byappropriate serologic profile

Prevention• Minimize or restrict exposures to livestock birthing areas• Dispose of birth products properly (e.g., incinerate placenta

and aborted fetuses)• Report all human cases to state health departments (Q fever

is a nationally notifiable disease)

http://www.cdc.gov/ncidod/dvrd/qfever/case_rep_fm.pdf

http://www.cdc.gov/ncidod/dvrd/qfever/case_rep_fm.pdf

http://www.cdc.gov/ncidod/dvrd/qfever

Vol. 51 / No. 41 MMWR 927

AcknowledgmentsThis report is based in part on data contributed by

G Rishwain, MD, E Schneider, MD, Stockton, California. WLamm, MD, Cumberland; J Roach, MD, Maryland Dept of Health.C Black, DVM, Georgia Dept of Agriculture. W Moore,R Wilson, DVM, Tennessee Dept of Health. J Childs, ScD,J Singleton, J Sumner, J Miller, Div of Viral and Rickettsial Diseases;W Shieh, MD, National Center for Infectious Diseases; J Perz,DrPH, EIS Officer, CDC.

References1. Rotz L, Khan A, Lillibridge S, et al. Public health assessment of poten-

tial biological terrorism agents. Emerg Infect Dis 2002;8:225–30.2. Raoult D, Mege JL, Marrie T. Q fever: queries remaining after decades

of research. In: Scheld WM, Craig WA, Hughes JM, eds. EmergingInfections 5. Washington DC: ASM Press, 2001:29–56.

3. McQuiston JH, Childs JE, Thompson HA. Q fever. J Am Vet MedAssoc 2002;221:796–9.

4. Marin M, Raoult D. Q fever. Clin Microbiol Rev 1999;12:518–53.5. Raoult D, Tissot-Dupont H, Foucault C, et al. Q fever 1985–1998:

clinical and epidemiologic features of 1,383 infections. Medicine2000;79:109–23.

6. Bernit E, Pouget J, Janbon F, et al. Neurological involvement in acuteQ fever: a report of 29 cases and review of the literature. Arch InternMed 2002;162:693–700.

7. Brouqui P, Tissot-Dupont H, Drancourt M, et al. Chronic Q fever:ninety-two cases from France, including 27 cases without endocardi-tis. Arch Intern Med 1993;153:642.

8. Raoult D, Houpikian P, Tissot-Dupont H, et al. Treatment of Q feverendocarditis: comparison of 2 regimens containing doxycyclineand ofloxacin or hydroxychloroquine. Arch Intern Med 1999;159:167–73.

9. Fenollar F, Fournier PE, Carrieri MP, et al. Risks factors and preven-tion of Q fever endocarditis. Clin Infect Dis 2001;33:312–6.

10. Fournier PE, Marrie TJ, Raoult D. Diagnosis of Q fever. J ClinMicrobiol 1998;36:1823–34.

Probable Variant Creutzfeldt-JakobDisease in a U.S. Resident —

Florida, 2002On April 18, 2002, the Florida Department of Health and

CDC announced the occurrence of a likely case of variantCreutzfeldt-Jakob disease (vCJD) in a Florida resident aged22 years. This report documents the investigation of this caseand underscores the importance of physicians increasing theirsuspicion for vCJD in patients presenting with clinical fea-tures described in this report who have spent time in areas inwhich bovine spongiform encephalopathy (BSE) is endemic.

In early November 2001, the patient sought medical carefor depression and memory loss that adversely affected thepatient’s work performance. The primary-care physicianreferred the patient to a psychologist. In early December 2001,the patient received a traffic ticket for failing to yield the

right of way. In mid-December 2001, the patient had invol-untary muscular movements, gait changes, difficulty dress-ing, and incontinence. In January 2002, the patient wasevaluated in a local emergency department for these symp-toms. A computerized tomography scan of the head revealedno abnormalities; a panic attack was diagnosed, and thepatient was treated with an anti-anxiety medication.

In late January 2002, the patient’s mother, a resident of theUnited Kingdom, took the patient to England, where medi-cal evaluations were conducted during the next 3 months.During this period, the patient’s memory loss and other neu-rologic symptoms worsened. The patient experienced falls withminor injuries, had difficulty taking a shower and dressing,and was unable to remember a home telephone number or tomake accurate mathematical calculations. The patient subse-quently became confused, hallucinated, and had speechabnormalities with lack of content, bradykinesia, and spastic-ity. The patient was referred to a neurologist, who suspectedvCJD and subsequently referred the patient to the NationalPrion Clinic in the United Kingdom.

Medical evaluations at the National Prion Clinic includedan electroencephalogram (EEG), which revealed a normalalpharhythm, and magnetic resonance imaging (MRI) stud-ies, which revealed signal abnormalities in the pulvinar andmetathalamus region that were suggestive of vCJD. Thepatient had a tonsil biopsy, and a Western blot analysis of thebiopsy tissue demonstrated the presence of protease-resistantprion protein (PrP-res) with the characteristic pattern of vCJD;an immunohistochemical test for PrP-res also supported adiagnosis of vCJD. Analysis of the prion protein genedetected no mutation and showed methionine homozygosityat codon 129, consistent with all 105 vCJD patients tested inthe United Kingdom (R. Will, Western General Hospital,Edinburgh, Scotland, personal communication, 2002).

The patient received experimental treatment with quina-crine for 3 months. As of late September 2002, the patienthad become bedridden, experienced considerable weight lossrequiring surgical insertion of a feeding tube, and was nolonger communicating with family members. On the basis ofa case definition developed in the United Kingdom, thepatient’s illness met criteria for a probable case of vCJD (1).

The patient was born in the United Kingdom in 1979 andmoved to Florida in 1992. The patient never had donated orreceived blood, plasma, or organs and never had receivedhuman growth hormone. There was no family history of CJD.In October 2001, before the onset of the illness, the patient’swisdom teeth were extracted, but there was no history of majorsurgery.


Reported by: S Wiersma, MD, State Epidemiologist, Florida Dept ofHealth. S Cooper, MRCP, R Knight, FRCP, National Creutzfeldt-JakobDisease Surveillance Unit, Western General Hospital, Edinburgh,Scotland; AM Kennedy, MD, National Prion Clinic, Dept of Neurology,St. Mary’s Hospital, London; S Joiner, MSc, Medical Research CouncilPrion Unit, Dept of Neurodegenerative Disease, Institute of Neurology,London, United Kingdom. E Belay, MD, LB Schonberger, MD, Div ofViral and Rickettsial Diseases, National Center for Infectious Diseases,CDC.

Editorial Note: Variant CJD was first reported in 1996 inthe United Kingdom, where an outbreak of BSE had beenoccurring among cattle since the early 1980s (2). Strong labo-ratory and epidemiologic evidence indicates that vCJD islinked causally with BSE (3). Although specific foods thattransmit the BSE agent to humans have not been identified,transmission is believed to occur primarily by processed fooditems that contain infectious bovine tissues such as the brainor spinal cord. As of early October 2002, a total of 138 vCJDcases were reported worldwide, including the case describedin this report. Consistent with the conclusion that the agentof BSE is also the agent responsible for vCJD, most vCJDcases (n=128) were reported in the United Kingdom, wheremost BSE cases in cattle have occurred (1).

The patient described in this report represents the first prob-able vCJD case in a U.S. resident. The patient had grown upin the United Kingdom when the BSE outbreak was increas-ing and when the risk for human exposures to BSE was prob-ably at its peak. Therefore, it is likely that this patient wasexposed to the BSE agent one or more times during 1980–1992 before moving to the United States and that the intervalbetween the patient’s exposure to BSE and onset of illnesswas 9–21 years. Such an incubation period would be consis-tent with known incubation periods for other similar diseasesin humans, such as kuru and CJD related to exposures topituitary-derived human growth hormone (4).

The patient is unlikely to have transmitted the disease toothers because the patient did not have surgical proceduresthat involved manipulation of known infectious tissues. Inaddition, the disease is not communicable by usual personalcontact. Appropriate infection-control procedures should befollowed while performing invasive procedures in patients withvCJD (5). Although concerns exist about possible trans-mission of vCJD by transfusion of blood, this risk remainstheoretical. The patient never had donated blood or organs.In 1999, because of the theoretical possibility of vCJD trans-missions from infected blood donors, blood collection agen-cies in the United States began implementing a donor-deferralpolicy to exclude donors who might be at increased risk forinfection because of a history of >6 months (later changed to

>3 months) residence or travel to the United Kingdom dur-ing 1980–1996. In 2001, this donor-deferral policy wasexpanded to exclude donors who have traveled to other Euro-pean countries for an extended period of time since 1980 (6).

Compared with the classic form of CJD endemic in theUnited States (7), vCJD patients typically have illness onsetat an unusually young age (median age: 26 years versusapproximately 68 years for classic CJD). All but one of thereported vCJD decedents had illness onset and died beforeage 55 years, compared with approximately 10% of classicCJD cases (7,8). Early in the course of the disease, vCJDpatients usually have early and persistent psychiatric symp-toms, including anxiety, depression, and social withdrawal;persistent painful sensory symptoms with dysesthesia and/orparasthesia also have been reported (8). Evaluation of the clini-cal manifestations of the first 100 vCJD patients in the UnitedKingdom indicated that onset of frank neurologic signs (e.g.,gait disturbances, slurring of speech, and tremor) was usuallydelayed by several months after illness onset. Other neuro-logic signs (e.g., chorea, dystonia, and myoclonus) frequentlydeveloped late in the course of the illness (8). A prominent,symmetrical pulvinar high signal on T2-weighted and/or pro-ton-density–weighted MRI has been reported in most vCJDpatients (9). In the absence of any other more plausible expla-nation, patients showing these clinical and radiologic featuresshould be investigated for vCJD. In such patients, a historyof travel to a BSE-endemic area increases the clinical suspi-cion for vCJD. In vCJD, but not other forms of CJD, there isprominent involvement of the lymphoreticular tissues (10).A tonsil biopsy with demonstration of a characteristic abnor-mal prion protein by Western blot and immunohistochemis-try can help establish a diagnosis of vCJD. The EEG in vCJDpatients is typically normal or shows nonspecific abnormali-ties. All 105 vCJD patients tested in the United Kingdomwere homozygous for methionine at the polymorphic codon129 of the prion protein gene (R. Will, Western GeneralHospital, Edinburgh, Scotland, personal communication,2002). The possible benefits of treating classic CJD and vCJDpatients with quinacrine are under evaluation.

Physicians should report suspected vCJD cases to theirlocal and state health departments. Because the clinical mani-festations and age distribution of vCJD patients can overlapwith those of classic CJD patients, a brain autopsy should beconducted in all such cases to distinguish suspected or diag-nosed vCJD from classic CJD. A neuropathologic evaluation,in addition to helping to confirm the diagnosis, would helpidentify other potentially emerging prion diseases in humans.To facilitate neuropathologic studies of suspected or diagnosedprion diseases in humans, CDC, in collaboration with the

Vol. 51 / No. 41 MMWR 929

American Association of Neuropathologists, establishedthe National Prion Disease Pathology Surveillance Center.Physicians are encouraged to use the free services of thispathology center to confirm the diagnosis in suspected vCJDor classic CJD patients. Information about the center is avail-able at http://www.cjdsurveillance.com.References1. Department of Health, United Kingdom. Monthly Creutzfeldt-Jakob

disease statistics, October 2002. Available at: http://www.doh.gov.uk/cjd/stats/oct02.htm.

2. Will RG, Ironside JW, Zeidler M, et al. A new variant of Creutzfeldt-Jakob disease in the UK. Lancet 1996;347:921–5.

3. Belay ED, Potter ME, Schonberger LB. Relationship between trans-missible spongiform encephalopathies in animals and humans. In: TaskForce Report of the Council for Agricultural Science and Technology.Washington, DC: Council for Agricultural Science and Technology,October 2000;No. 136.

4. Will RG, Alpers MP, Dormont D, Schonberger LB, Tateishi J. Infec-tious and sporadic prion diseases. In: Prusiner SB, ed. Prion Biologyand Diseases. Cold Spring, New York: Cold Spring Laboratory Press,1999.

5. World Health Organization. World Health Organization infection con-trol guidelines for transmissible spongiform encephalopathies:report of a World Health Organization consultation. Geneva, Switzer-land: World Health Organization, March 1999. Available at http://www.who.int/emc-documents/tse/whocdscsraph2003c.html.

6. U.S. Food and Drug Administration. Revised preventive measures toreduce the possible risk of transmission of Creutzfeldt-Jakob diseaseand variant Creutzfeldt-Jakob disease by blood and blood products.Rockville, Maryland: U.S. Department of Health and Human Ser-vices, January 2002. Available at http://www.fda.gov/cber/gdlns/cjdvcjd.htm.

7. Gibbons RV, Holman RC, Belay ED, Schonberger LB. Creutzfeldt-Jakob disease in the United States: 1979–1998. JAMA 2000;284:2322–3.

8. Spencer MD, Knight RSG, Will RG. First hundred cases of variantCreutzfeldt-Jakob disease: retrospective case note review of earlypsychiatric and neurological features. BMJ 2002;324:1479–82.

9. Zeidler M, Sellar RJ, Collie DA, et al. The pulvinar sign on magneticresonance imaging in variant Creutzfeldt-Jakob disease. Lancet2000;355:1412–8.

10. Hill AF, Butterworth RJ, Joiner S, et al. Investigation of variantCreutzfeldt-Jakob disease and other human prion diseases with tonsilbiopsy samples. Lancet 1999;353:183–9.

West Nile Virus Activity —United States, October 10–16, 2002,

and Update on West Nile VirusInfections in Recipientsof Blood Transfusions

This report summarizes West Nile virus (WNV) surveil-lance data reported to CDC through ArboNET and by statesand other jurisdictions as of 8 a.m. Mountain Daylight Time,October 16, 2002.

WNV SurveillanceDuring October 10–16, a total of 256 laboratory-positive

human cases of WNV-associated illness were reported fromIndiana (n=47), Nebraska (n=34), Michigan (n=32), Ohio(n=28), Illinois (n=21), Missouri (n=11), Pennsylvania (n=10),the District of Columbia (n=seven), Iowa (n=six), Kansas(n=six), Kentucky (n=six), Louisiana (n=six), Texas (n=six),Maryland (n=five), Georgia (n=four), South Dakota (n=four),Tennessee (n=four), Mississippi (n=three), New York(n=three), Virginia (n=three), Florida (n=two), Massachusetts(n=two), Minnesota (n=two), Connecticut (n=one), New Jer-sey (n=one), Vermont (n=one), and Wyoming (n=one). Dur-ing this reporting period, Kansas, Vermont, and Wyomingreported their first human cases of WNV infection. Duringthe same period, WNV infections were reported in 218 deadcrows and 97 other dead birds. A total of 1,135 veterinarycases (1,026 equine and one other species) and 424 WNV-positive mosquito pools were reported.

During 2002, a total of 3,052 human cases with laboratoryevidence of recent WNV infection have been reported fromIllinois (n=675), Michigan (n=433), Ohio (n=341), Louisi-ana (n=299), Indiana (n=204), Mississippi (n=171), Missouri(n=149), Nebraska (n=114), Texas (n=107), New York (n=63),Kentucky (n=50), Pennsylvania (n=47), Tennessee (n=44),Alabama (n=39), Iowa (n=39), South Dakota (n=37), Min-nesota (n=33), Wisconsin (n=28), Georgia (n=23), Virginia(n=23), Maryland (n=19), Massachusetts (n=19), NorthDakota (n=15), the District of Columbia (n=13), Connecti-cut (n=12), Florida (n=12), Arkansas (n=11), New Jersey(n=eight), Kansas (n=six), Colorado (n=five), Oklahoma(n=four), North Carolina (n=two), West Virginia (n=two),California (n=one), Rhode Island (n=one), South Carolina(n=one), Vermont (n=one), and Wyoming (n=one) (Figure).Among the 2,661 patients for whom data were available, themedian age was 56 years (range: 1 month–99 years); 1,416(54%) were male, and the dates of illness onset ranged fromJune 10 to October 6. A total of 153 human deaths have beenreported. The median age of decedents was 79 years (range:27–99 years); 93 (61%) deaths were among men. In addi-tion, 6,289 dead crows and 4,611 other dead birds with WNVinfection were reported from 42 states and the District ofColumbia; 6,427 WNV infections in mammals (6,418equines, three canines, and six other species) have beenreported from 35 states (Alabama, Arkansas, Colorado, Dela-ware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Ken-tucky, Louisiana, Maryland, Massachusetts, Minnesota,Mississippi, Missouri, Montana, Nebraska, New Jersey, NewMexico, New York, North Carolina, North Dakota, Ohio,

http://www.cjdsurveillance.com

http://www.doh.gov.uk/cjd/stats/oct02.htm

http://www.doh.gov.uk/cjd/stats/oct02.htm

http://www.who.int/emc-documents/tse/whocdscsraph2003c.html

http://www.who.int/emc-documents/tse/whocdscsraph2003c.html

http://www.fda.gov/cber/gdlns/cjdvcjd.htm

http://www.fda.gov/cber/gdlns/cjdvcjd.htm


Oklahoma, Pennsylvania, South Carolina, South Dakota,Tennessee, Texas, Vermont, Virginia, Wisconsin, and Wyo-ming). During 2002, WNV seroconversions have beenreported in 342 sentinel chicken flocks from Florida, Iowa,Nebraska, Pennsylvania, and New York City; 4,434 WNV-positive mosquito pools have been reported from 26 states(Alabama, Arkansas, Connecticut, Delaware, Georgia, Illinois,Indiana, Iowa, Kentucky, Maryland, Massachusetts, Missis-sippi, Missouri, Nebraska, New Hampshire, New Jersey, NewYork, North Carolina, Ohio, Pennsylvania, Rhode Island,South Carolina, South Dakota, Texas, Vermont, and Virginia),New York City, and the District of Columbia.

Additional information about WNV activity is availablefrom CDC at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://www.cindi.usgs.gov/hazard/event/west_nile/west_nile.html.

WNV Infections in Recipients of BloodTranfusions

CDC, the Food and Drug Administration, and the HealthResources and Services Administration, in collaboration withblood collection agencies and state and local health depart-ments, continue to investigate West Nile virus (WNV) infec-tions in recipients of blood transfusion. During August28–October 16, CDC received reports from 14 states of 25patients with West Nile meningoencephalitis (WNME) andfour with other WNV-associated illnesses diagnosed afterreceiving blood components in the month before illnessonset. All 29 of these patients resided in areas with high levels

of WNV activity. CDC has been notified of one additionalcase, but demographic and clinical information is pending.Investigations are ongoing to determine whether transfusionwas the source of WNV transmission. To date, four investi-gations provide evidence that WNV can be transmittedthrough blood transfusion.

Of the 29 cases, 14 (48%) were reported since October 1.Of the 24 patients for whom an illness onset date was speci-fied, illness began in July (two patients), August (eight),September (13), and October (one); one additional patient,an organ donor, had West Nile viremia at the time of organrecovery in late July following receipt of multiple blood trans-fusions (1). Among these patients, the reason for hospitaliza-tion or the underlying conditions included a surgicalprocedure or obstetric delivery (eight); solid organ transplan-tation (four patients who received an organ from differentdonors who did not have evidence of WNV infection at thetime of organ recovery); hematologic conditions (includingmyelodysplasia [three patients], acute myelogenous leukemia[five], acute lymphocytic leukemia [one], non-Hodgkin’s lym-phoma [one], thrombotic thrombocytopenic purpura [one]);and other medical conditions (six patients). These 29 patientsreceived blood components from a median of 17 donors(range: two–185 donors). Among nine patients who died,WNME was the probable cause of death.

Among the four cases that provided evidence that WNVcan be transmitted through blood transfusion, two patientsdeveloped confirmed WNME after receiving different bloodcomponents derived from a single blood donation that wassubsequently found to have evidence of WNV (2). In follow-up testing, this donor seroconverted and developed WNVIgM antibody. In another case, WNV was isolated from awithdrawn unit of frozen plasma from the suspected dona-tion, indicating that the virus can survive in some blood com-ponents (1). The donor of this plasma subsequently developedan acute febrile illness and seroconverted following the sus-pect collection. In a fourth case, a patient who had been hos-pitalized for 65 days developed WNME after receiving acomponent derived from a suspected donation that containedWNV RNA. Follow-up found that the donor had developeda febrile illness compatible with WNV-associated fever withindays of the suspect donation; serology testing is pending.

Cases of WNV infection in patients who have received bloodtransfusions within the 4 weeks preceding illness onset shouldbe reported to CDC through state and local public healthauthorities. Serum or tissue samples should be retained forlater studies. In addition, cases of WNV infection in personswith illness onset within 2 weeks after blood donation should

FIGURE. Areas reporting West Nile virus (WNV) activity —United States, 2002*

* As of 8 a.m. Mountain Daylight Time, October 16, 2002.†

California has reported human WNV activity only.

Recent human WNV infection and animal WNV activity (human cases)

Animal WNV activity only

(107)(299)

(171) (39)

(675)(204)

(12)

(63)

(50)

(44)

(149)

(341)

(4)

(114)

(37) (28)(433)

(23)

(23)

(15)(33)

(39) (47)

(1)(11)

(1)† (5)

(2)

CTDCMAMDNJRIVT

(12)(13)(19)(19)( 8)( 1)( 1)

(2)

(1)

(6)

http://www.cdc.gov/ncidod/dvbid/westnile/index.htm


http://cindi.usgs.gov/hazard/event/west_nile/west_nile.html


Vol. 51 / No. 41 MMWR 931

be reported. Prompt reporting of these cases willfacilitate withdrawal of potentially infectious blood compo-nents.

Additional information about WNV activity is availablefrom CDC at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://www.cindi.usgs.gov/hazard/event/west_nile/west_nile.html.References1. CDC. Update: investigations of West Nile virus infections in recipients

of organ transplantation and blood transfusion. MMWR 2002;51:833–6.2. CDC. Update: investigation of West Nile virus infections in recipients

of organ transplantation and blood transfusion—Michigan, 2002.MMWR 2002;51:879.

Notice to Readers

Pneumococcal Vaccination for CochlearImplant Recipients

CDC and the Food and Drug Administration, in collabo-ration with state health departments, are investigating theoccurrence of bacterial meningitis among cochlearimplant recipients (1,2). The implant, as a foreign body, andthe design of the electrode are considered possible risk fac-tors. Other potential risk factors for meningitis amongcochlear implant recipients include a history of meningitis(a leading cause of sensorineural hearing loss), a history ofrecurrent otitis media, immunodeficiency, a pre-existinginner ear abnormality, and an occult cerebrospinal fluid leak.

As of October 4, 2002, a total of 53 cases of meningitiswere reported in the United States among cochlear implantrecipients (2). In the United States, approximately 21,000persons have cochlear implants (3). Of the 23 cases for whichbacterial culture results were available, 16 were caused byStreptococcus pneumoniae (pneumococcus) (2).

Vaccination against pneumococcal disease is recommendedby the Advisory Committee on Immunization Practices(ACIP) for persons at increased risk for pneumococcal men-ingitis. Because preliminary data suggest a higher risk for pneu-mococcal meningitis in cochlear implant recipients, CDCrecommends that all persons with cochlear implants receive

age-appropriate vaccination against pneumococcal disease asrecommended for other persons at high risk for invasive pneu-mococcal disease; recommendations will be reviewed aftercompletion of the investigation. These persons should receivethe 7-valent pneumococcal conjugate (Prevnar®) or 23-valent pneumococcal polysaccharide (Pneumovax® and Pnu-Imune®) vaccine, or both, according to ACIP schedules forpersons at high risk (4,5). During the current pneumococcalconjugate vaccine shortage, children aged <5 years withcochlear implants should be given the same priority for avail-able vaccine as children in other high-risk groups (6). Addi-tional information on the use of vaccines for cochlear implantrecipients is available from CDC’s National ImmunizationProgram at http://www.cdc.gov/nip/issues/cochlear/cochlear-hcp.htm.References1. CDC. Cochlear implants and meningitis, frequently asked questions.

Available at http://www.cdc.gov/ncbddd.2. Food and Drug Administration. Public health web notification:

cochlear implant recipients may be at greater risk for meningitis. Avail-able at http://www.fda.gov/cdrh/safety/cochlear.html.

3. National Institute on Deafness and Other Communication Disorders.Health information, hearing and balance. Available at http://www.nidcd.nih.gov/health/pubs_hb/coch.htm.

4. CDC. Preventing pneumococcal disease among infants and young chil-dren: recommendations of the Advisory Committee on ImmunizationPractices (ACIP). MMWR 2000;49(No. RR-9).

5. CDC. Prevention of pneumococcal disease: recommendations of theAdvisory Committee on Immunization Practices (ACIP). MMWR1997;46(No. RR-8).

6. CDC. Updated recommendations on the use of pneumococcal conju-gate vaccine in a setting of vaccine shortage—Advisory Committee onImmunization Practices. MMWR 2001;50:1140–2.

Erratum: Vol. 51, No. 40In the report “Vancomycin-Resistant Staphylococcus aureus—

Pennsylvania, 2002,” on page 902, reference 3 was incorrect.The reference should be:3. National Committee for Clinical Laboratory Standards. Methods for

dilution antimicrobial susceptibility tests for bacteria that grow aerobi-cally. 5th ed. Approved standard, M7-A5. Wayne, Pennsylvania:National Committee for Laboratory Standards, 2000.





http://www.cdc.gov/nip/issues/cochlear/cochlear-hcp.htm

http://www.cdc.gov/nip/issues/cochlear/cochlear-hcp.htm

http://www.cdc.gov/ncbddd

http://www.fda.gov/cdrh/safety/cochlear.html

http://www.nidcd.nih.gov/health/pubs_hb/coch.htm

http://www.nidcd.nih.gov/health/pubs_hb/coch.htm

Erica Shaver

Erica Shaver

Erica Shaver

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5140a3.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5140a3.htm

Vol. 51 / No. 41 MMWR 933

* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area beginsis based on the mean and two standard deviations of these 4-week totals.

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals ending October 12, 2002, withhistorical data

DISEASE DECREASE INCREASECASES CURRENT

4 WEEKS

Ratio (Log Scale)*

Beyond Historical Limits

4210.50.250.125

442

368

78

113

1

58

19

436

6

Hepatitis A, Acute

Hepatitis B, Acute

Hepatitis C; Non-A, Non-B, Acute

Legionellosis

Measles, Total

Mumps

Pertussis

Rubella

Meningococcal Infections

TABLE I. Summary of provisional cases of selected notifiable diseases, United States, cumulative, week ending October 12, 2002 (41st Week)*

Cum. Cum. Cum. Cum.2002 2001 2002 2001

-:No reported cases.* Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).†Not notifiable in all states.

§Updated monthly from reports to the Division of HIV/AIDS Prevention — Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention(NCHSTP). Last update September 29, 2002.

Anthrax 2 4 Encephalitis: West Nile† 900 46Botulism: foodborne 11 33 Hansen disease (leprosy)† 61 53

infant 43 77 Hantavirus pulmonary syndrome† 11 7other (wound & unspecified) 19 13 Hemolytic uremic syndrome, postdiarrheal† 155 137

Brucellosis† 62 102 HIV infection, pediatric†§ 137 147Chancroid 57 29 Plague - 2Cholera 4 4 Poliomyelitis, paralytic - -Cyclosporiasis† 160 127 Psittacosis† 17 12Diphtheria 1 2 Q fever† 34 21Ehrlichiosis: human granulocytic (HGE)† 259 187 Rabies, human 2 1

human monocytic (HME)† 129 97 Streptococcal toxic-shock syndrome† 64 62other and unspecified 7 5 Tetanus 18 26

Encephalitis: California serogroup viral† 95 83 Toxic-shock syndrome 90 94eastern equine† 2 8 Trichinosis 12 20Powassan† - - Tularemia† 52 114St. Louis† 1 75 Yellow fever 1 -western equine† 2 -


N: Not notifiable. U: Unavailable. -: No reported cases. C.N.M.I.: Commonwealth of Northern Mariana Islands.* Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).† Chlamydia refers to genital infections caused by C. trachomatis.§ Updated monthly from reports to the Division of HIV/AIDS Prevention — Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention. Last update

September 29, 2002.

TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending October 12, 2002, and October 13, 2001(41st Week)*

Shiga Toxin Positive,AIDS Chlamydia† Cryptosporidiosis O157:H7 Serogroup non-O157

Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum.Reporting Area 2002§ 2001 2002 2001 2002 2001 2002 2001 2002 2001

Escherichia coli, Enterohemorrhagic

UNITED STATES 31,555 30,610 594,396 604,247 2,180 3,108 2,744 2,535 131 116

NEW ENGLAND 1,236 1,116 20,631 18,899 145 122 223 213 29 35Maine 27 36 1,322 1,046 10 15 32 25 5 1N.H. 25 27 1,260 1,092 26 10 28 29 - 3Vt. 12 13 727 486 28 30 8 13 1 1Mass. 629 595 8,549 8,086 50 47 104 106 9 9R.I. 82 76 2,146 2,322 16 4 12 11 - 1Conn. 461 369 6,627 5,867 15 16 39 29 14 20

MID. ATLANTIC 7,170 7,965 68,162 65,357 252 279 193 191 - -Upstate N.Y. 482 1,079 13,321 10,520 101 82 146 123 - -N.Y. City 4,225 4,361 22,355 23,704 104 102 11 15 - -N.J. 1,117 1,345 10,141 10,651 9 14 36 53 - -Pa. 1,346 1,180 22,345 20,482 38 81 N N - -

E.N. CENTRAL 3,291 2,223 102,866 111,628 672 1,417 685 647 14 7Ohio 663 424 23,697 29,369 106 143 131 141 12 5Ind. 422 264 13,097 12,282 35 69 55 71 - -Ill. 1,556 989 27,835 33,692 69 464 144 155 - -Mich. 500 411 25,666 23,337 86 157 111 80 2 2Wis. 150 135 12,571 12,948 376 584 244 200 - -

W.N. CENTRAL 507 636 33,370 30,796 337 430 408 416 29 33Minn. 113 105 7,497 6,454 179 137 144 164 25 27Iowa 67 73 4,086 3,967 37 74 99 70 - -Mo. 229 302 11,960 10,988 32 40 54 52 N NN. Dak. 1 2 740 806 6 12 3 18 - 2S. Dak. 4 22 1,710 1,403 27 6 35 37 1 3Nebr. 44 61 2,362 2,531 43 158 44 56 3 1Kans. 49 71 5,015 4,647 13 3 29 19 - -

S. ATLANTIC 9,368 9,405 111,873 117,270 270 305 239 195 36 22Del. 155 202 2,030 2,230 3 6 7 4 - 1Md. 1,412 1,494 12,628 11,944 20 32 23 26 - -D.C. 453 639 2,576 2,564 4 11 - - - -Va. 612 763 12,245 14,188 11 22 52 46 9 2W. Va. 72 59 1,859 1,854 2 2 7 10 - -N.C. 782 699 19,077 17,684 30 24 36 41 - -S.C. 649 565 9,451 12,488 6 7 5 13 - -Ga. 1,356 1,027 22,729 25,178 121 135 51 30 10 9Fla. 3,877 3,957 29,278 29,140 73 66 58 25 17 10

E.S. CENTRAL 1,469 1,401 37,349 39,097 103 41 88 119 - -Ky. 253 278 6,557 7,007 5 4 27 59 - -Tenn. 620 438 12,630 11,590 50 12 37 35 - -Ala. 298 347 10,137 10,835 42 13 17 16 - -Miss. 298 338 8,025 9,665 6 12 7 9 - -

W.S. CENTRAL 3,336 3,087 82,274 84,469 32 110 55 163 - -Ark. 190 156 5,133 5,953 7 6 9 13 - -La. 815 652 15,448 14,500 5 7 2 7 - -Okla. 156 187 8,658 8,123 15 12 19 26 - -Tex. 2,175 2,092 53,035 55,893 5 85 25 117 - -

MOUNTAIN 1,043 1,068 37,199 36,207 135 182 301 235 17 13Mont. 9 14 1,712 1,493 4 28 25 16 - -Idaho 24 17 1,966 1,511 27 20 42 54 8 2Wyo. 8 3 706 642 9 6 12 8 2 2Colo. 212 244 10,983 10,278 49 37 82 81 3 6N. Mex. 65 107 5,123 4,943 18 21 9 11 3 3Ariz. 444 417 11,944 11,323 12 7 33 21 1 -Utah 53 87 1,982 1,931 12 58 74 29 - -Nev. 228 179 2,783 4,086 4 5 24 15 - -

PACIFIC 4,134 3,709 100,672 100,524 234 222 552 356 6 6Wash. 386 385 11,443 10,660 43 U 135 98 - -Oreg. 260 154 5,320 5,754 31 46 186 62 6 6Calif. 3,379 3,098 77,674 78,866 158 172 188 175 - -Alaska 22 17 2,806 2,081 - 1 6 4 - -Hawaii 87 55 3,429 3,163 2 3 37 17 - -

Guam 2 9 - 323 - - N N - -P.R. 915 932 1,870 2,052 - - - 2 - -V.I. 67 2 125 124 - - - - - -Amer. Samoa U U U U U U U U U UC.N.M.I. 2 U 138 U - U - U - U

Vol. 51 / No. 41 MMWR 935

N: Not notifiable. U: Unavailable. - : No reported cases.* Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending October 12, 2002, and October 13, 2001(41st Week)*

Haemophilus influenzae,Escherichia coli Invasive

Enterohemorrhagic Age <5 YearsShiga Toxin Positive, All Ages, Serotype

Not Serogrouped Giardiasis Gonorrhea All Serotypes BCum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum.

Reporting Area 2002 2001 2002 2002 2001 2002 2001 2002 2001

UNITED STATES 30 13 12,904 251,296 279,775 1,184 1,164 17 20

NEW ENGLAND - 1 1,317 5,782 5,325 82 87 - 1Maine - - 165 110 107 1 2 - -N.H. - - 32 104 146 7 4 - -Vt. - 1 106 80 53 7 3 - -Mass. - - 658 2,591 2,484 42 39 - 1R.I. - - 128 699 644 10 3 - -Conn. - - 228 2,198 1,891 15 36 - -

MID. ATLANTIC - 1 2,799 31,224 32,323 215 172 3 3Upstate N.Y. - - 949 6,820 6,547 98 56 2 -N.Y. City - - 1,050 9,255 9,965 51 43 - -N.J. - - 275 5,682 5,530 45 40 - -Pa. - 1 525 9,467 10,281 21 33 1 3

E.N. CENTRAL 11 5 2,436 49,834 58,879 176 217 3 2Ohio 10 5 731 13,138 16,397 65 56 - 1Ind. - - - 5,649 5,367 36 43 1 -Ill. - - 564 14,944 18,756 57 77 - -Mich. 1 - 685 11,582 13,629 11 12 2 -Wis. - - 456 4,521 4,730 7 29 - 1

W.N. CENTRAL - 3 1,571 13,050 13,087 51 58 1 1Minn. - - 632 2,291 2,053 37 32 1 -Iowa - - 243 944 1,042 1 - - -Mo. N N 378 6,817 6,770 10 16 - -N. Dak. - 3 11 42 37 - 7 - -S. Dak. - - 58 205 226 - - - -Nebr. - - 122 711 912 - 2 - 1Kans. - - 127 2,040 2,047 3 1 - -

S. ATLANTIC - - 2,226 64,302 73,015 306 288 2 1Del. - - 42 1,217 1,342 - - - -Md. - - 100 6,770 7,119 71 72 2 -D.C. - - 32 2,126 2,293 - - - -Va. - - 206 7,510 8,412 27 25 - -W. Va. - - 45 737 527 14 14 - 1N.C. - - - 12,502 13,746 30 42 - -S.C. - - 112 5,730 9,019 12 4 - -Ga. - - 709 12,526 13,838 78 73 - -Fla. - - 980 15,184 16,719 74 58 - -

E.S. CENTRAL 8 2 300 21,473 25,261 55 63 1 -Ky. 8 2 - 2,792 2,779 4 2 - -Tenn. - - 137 7,352 7,801 28 33 - -Ala. - - 163 6,535 8,386 16 26 1 -Miss. - - - 4,794 6,295 7 2 - -

W.S. CENTRAL - - 186 36,692 41,662 51 44 2 1Ark. - - 130 3,044 3,712 2 - - -La. - - 3 9,528 10,040 7 8 - -Okla. - - 53 3,710 3,734 37 35 - -Tex. - - - 20,410 24,176 5 1 2 1

MOUNTAIN 11 1 1,299 7,904 8,197 140 125 2 7Mont. - - 74 76 84 - - - -Idaho - - 99 70 61 2 1 - -Wyo. - - 25 49 64 1 1 - -Colo. 11 1 422 2,708 2,483 26 34 - -N. Mex. - - 131 1,047 787 21 20 - 1Ariz. - - 173 2,939 3,076 64 52 1 4Utah - - 257 198 148 16 6 - -Nev. - - 118 817 1,494 10 11 1 2

PACIFIC - - 770 21,035 22,026 108 110 3 4Wash. - - 289 2,269 2,372 3 2 2 -Oreg. - - 324 676 904 51 32 - -Calif. - - - 17,087 17,932 22 49 1 4Alaska - - 84 468 332 1 6 - -Hawaii - - 73 535 486 31 21 - -

Guam - - - - 39 - - - -P.R. - - 33 281 468 1 1 - -V.I. - - - 31 21 - - - -Amer. Samoa U U U U U U U U UC.N.M.I. - U 1 13 U - U - U


N: Not notifiable. U: Unavailable. -: No reported cases.* Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).


Haemophilus influenzae, Invasive

Age <5 Years Hepatitis (Viral, Acute), By Type

Non-Serotype B Unknown Serotype A B C; Non-A, Non-BCum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum.

Reporting Area 2002 2001 2002 2001 2002 2001 2002 2001 2002 2001

UNITED STATES 193 190 14 24 6,599 7,875 5,337 5,596 12,103 3,186

NEW ENGLAND 9 15 - - 245 541 200 105 20 31Maine - - - - 8 10 8 5 - -N.H. - 1 - - 11 15 18 11 - -Vt. - - - - 1 12 4 5 12 6Mass. 6 7 - - 110 257 110 22 8 25R.I. - - - - 30 46 24 22 - -Conn. 3 7 - - 85 201 36 40 - -

MID. ATLANTIC 27 25 - 3 816 1,004 1,147 1,075 1,340 1,051Upstate N.Y. 11 7 - 1 151 203 107 98 56 24N.Y. City 8 7 - - 370 353 578 502 - -N.J. 5 4 - - 114 240 283 231 1,257 971Pa. 3 7 - 2 181 208 179 244 27 56

E.N. CENTRAL 27 34 1 2 872 977 638 740 79 141Ohio 7 9 1 - 274 187 81 85 7 8Ind. 7 6 - 1 39 87 38 42 - 1Ill. 11 13 - - 234 367 105 116 12 9Mich. 1 - - 1 190 272 414 461 60 123Wis. 1 6 - - 135 64 - 36 - -

W.N. CENTRAL 3 3 3 6 257 314 175 168 680 936Minn. 3 2 1 2 37 34 21 17 - 9Iowa - - - - 67 29 12 19 1 -Mo. - - 2 4 72 70 97 96 665 915N. Dak. - 1 - - 1 3 4 1 - -S. Dak. - - - - 3 2 1 1 1 -Nebr. - - - - 17 31 22 23 9 5Kans. - - - - 60 145 18 11 4 7

S. ATLANTIC 47 40 1 6 1,967 1,737 1,358 1,149 139 80Del. - - - - 11 13 7 21 5 8Md. 4 7 - 1 247 195 99 116 6 7D.C. - - - - 65 43 18 11 - -Va. 4 5 - - 107 109 160 139 9 -W. Va. 1 1 1 1 17 18 18 20 2 9N.C. 3 2 - 4 190 173 194 173 22 18S.C. 2 1 - - 55 64 102 26 4 6Ga. 17 16 - - 385 775 338 332 29 -Fla. 16 8 - - 890 347 422 311 62 32

E.S. CENTRAL 11 12 1 3 208 323 279 379 162 175Ky. 1 - - 1 41 114 45 47 3 9Tenn. 6 6 - 1 89 117 103 187 25 59Ala. 3 5 1 1 32 68 61 75 5 4Miss. 1 1 - - 46 24 70 70 129 103

W.S. CENTRAL 12 7 - - 423 726 419 619 9,541 615Ark. 1 - - - 31 61 68 76 5 9La. 2 2 - - 39 77 65 102 34 129Okla. 7 5 - - 46 101 42 83 5 4Tex. 2 - - - 307 487 244 358 9,497 473

MOUNTAIN 34 20 7 1 480 603 498 379 54 46Mont. - - - - 13 10 8 3 - 1Idaho 1 - - - 24 51 6 10 - 2Wyo. - - - - 3 7 17 2 5 5Colo. 2 2 - - 70 76 63 82 17 6N. Mex. 6 8 1 1 24 34 122 108 1 11Ariz. 16 8 5 - 256 309 192 115 4 9Utah 5 2 - - 51 59 46 20 4 3Nev. 4 - 1 - 39 57 44 39 23 9

PACIFIC 23 34 1 3 1,331 1,650 623 982 88 111Wash. 1 1 - 1 135 114 53 115 17 19Oreg. 5 5 - - 55 90 99 132 15 13Calif. 13 26 1 1 1,130 1,416 462 709 56 79Alaska 1 1 - - 9 14 3 9 - -Hawaii 3 1 - 1 2 16 6 17 - -

Guam - - - - - 1 - - - -P.R. - 1 - - 87 174 75 218 - 1V.I. - - - - - - - - - -Amer. Samoa U U U U U U U U U UC.N.M.I. - U - U - U 37 U - U

Vol. 51 / No. 41 MMWR 937

N: Not notifiable. U: Unavailable. -: No reported cases.* Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).† Of 22 cases reported, 10 were indigenous and 12 were imported from another country.§ Of 106 cases reported, 53 were indigenous and 53 were imported from another country.


MeaslesLegionellosis Listeriosis Lyme Disease Malaria Total

Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum.Reporting Area 2002 2001 2002 2001 2002 2001 2002 2001 2002 2001

UNITED STATES 810 839 428 479 11,967 12,347 988 1,201 22† 106§

NEW ENGLAND 75 54 48 43 3,475 3,576 50 78 - 5Maine 2 7 5 - 53 - 5 4 - -N.H. 4 8 4 4 203 72 7 2 - -Vt. 30 5 3 2 27 16 4 1 - 1Mass. 26 19 24 22 961 1,040 15 42 - 3R.I. 2 6 1 1 288 413 5 7 - -Conn. 11 9 11 14 1,943 2,035 14 22 - 1

MID. ATLANTIC 216 200 122 88 6,974 6,690 231 364 7 19Upstate N.Y. 71 54 50 24 4,074 2,680 36 53 1 4N.Y. City 43 39 25 20 125 61 145 218 6 6N.J. 21 20 24 16 866 1,888 28 54 - 1Pa. 81 87 23 28 1,909 2,061 22 39 - 8

E.N. CENTRAL 199 230 45 74 68 673 111 147 3 10Ohio 88 93 19 12 50 33 17 21 1 3Ind. 17 17 6 8 18 22 11 15 2 4Ill. - 23 1 22 - 30 28 61 - 3Mich. 66 58 15 22 - 5 43 32 - -Wis. 28 39 4 10 U 583 12 18 - -

W.N. CENTRAL 42 44 14 15 197 340 51 32 3 4Minn. 11 9 3 - 119 277 16 6 1 2Iowa 9 8 1 2 31 27 4 6 - -Mo. 11 18 6 8 35 30 14 12 2 2N. Dak. - 1 1 - - - 1 - - -S. Dak. 2 3 1 - 1 - 1 - - -Nebr. 9 4 1 1 5 4 5 2 - -Kans. - 1 1 4 6 2 10 6 - -

S. ATLANTIC 154 141 65 60 1,058 836 300 243 2 5Del. 7 8 - 2 138 144 3 2 - -Md. 30 30 14 11 568 509 96 100 - 3D.C. 5 7 - - 20 10 17 13 - -Va. 18 20 7 11 129 110 28 43 - 1W. Va. N N - 5 16 10 3 1 - -N.C. 10 7 6 4 103 35 19 13 - -S.C. 6 10 8 5 18 5 7 6 - -Ga. 12 11 10 11 2 - 69 39 - 1Fla. 66 48 20 11 64 13 58 26 2 -

E.S. CENTRAL 28 52 14 21 38 56 19 33 - 2Ky. 11 12 2 7 20 22 7 13 - 2Tenn. 10 24 8 8 18 19 3 11 - -Ala. 7 12 4 6 - 8 4 5 - -Miss. - 4 - - - 7 5 4 - -

W.S. CENTRAL 8 20 12 31 18 77 14 73 2 1Ark. - - - 1 3 - 2 3 - -La. 1 6 - - 2 7 4 6 - -Okla. 3 3 7 2 - - 8 2 - -Tex. 4 11 5 28 13 70 - 62 2 1

MOUNTAIN 36 43 26 32 18 10 40 47 1 2Mont. 3 - - - - - 2 2 - -Idaho 1 3 2 1 4 5 - 3 - 1Wyo. 1 2 - 1 1 1 - - - -Colo. 6 13 6 9 3 - 21 21 - -N. Mex. 2 2 2 7 1 - 2 3 - -Ariz. 8 15 12 6 2 - 7 7 - 1Utah 11 5 3 2 6 1 5 3 - -Nev. 4 3 1 6 1 3 3 8 1 -

PACIFIC 52 55 82 115 121 89 172 184 4 58Wash. 5 7 8 7 9 7 16 8 - 15Oreg. N N 8 11 14 9 9 13 - 3Calif. 46 42 58 91 95 71 138 151 3 33Alaska - 1 - - 3 2 2 1 - -Hawaii 1 5 8 6 N N 7 11 1 7

Guam - - - - - - - 1 - -P.R. - 2 1 - N N - 5 - 1V.I. - - - - - - - - - -Amer. Samoa U U U U U U U U U UC.N.M.I. - U - U - U - U - U




MeningococcalDisease Mumps Pertussis Rabies, Animal

Cum. Cum. Cum. Cum. Cum. Cum. Cum. Cum.Reporting Area 2002 2001 2002 2001 2002 2001 2002 2001

UNITED STATES 1,344 1,868 209 191 5,853 4,199 4,810 5,775

NEW ENGLAND 79 86 7 1 497 385 750 596Maine 7 3 - - 12 21 49 55N.H. 11 11 4 - 16 15 40 19Vt. 4 5 - - 98 28 85 55Mass. 39 47 2 1 333 299 234 219R.I. 5 4 - - 13 5 66 53Conn. 13 16 1 - 25 17 276 195

MID. ATLANTIC 127 208 22 23 334 284 904 1,074Upstate N.Y. 37 53 5 3 250 118 565 650N.Y. City 21 35 1 11 10 46 10 28N.J. 25 34 - 3 3 18 152 162Pa. 44 86 16 6 71 102 177 234

E.N. CENTRAL 178 289 25 23 707 664 135 130Ohio 68 75 8 1 349 253 33 42Ind. 28 33 2 1 103 67 30 2Ill. 36 73 7 16 113 72 30 24Mich. 34 63 7 3 43 103 42 44Wis. 12 45 1 2 99 169 - 18

W.N. CENTRAL 122 124 15 7 563 212 329 314Minn. 29 18 3 3 263 70 36 40Iowa 18 25 1 - 127 23 62 73Mo. 41 43 5 - 116 87 45 37N. Dak. - 6 1 - - 4 12 33S. Dak. 2 5 - - 6 4 65 44Nebr. 25 13 - 1 6 4 - 4Kans. 7 14 5 3 45 20 109 83

S. ATLANTIC 243 288 23 33 348 198 1,946 1,990Del. 7 3 - - 2 - 24 30Md. 7 38 5 5 55 33 199 409D.C. - - - - 2 1 - -Va. 36 33 3 6 117 35 397 373W. Va. 4 12 - - 30 2 149 118N.C. 29 60 1 4 38 58 592 473S.C. 26 29 2 5 40 31 113 94Ga. 29 43 4 8 18 20 303 341Fla. 105 70 8 5 46 18 169 152

E.S. CENTRAL 77 119 11 7 209 132 139 192Ky. 12 20 3 1 79 38 24 25Tenn. 32 53 2 1 92 56 93 106Ala. 20 30 3 - 31 34 22 57Miss. 13 16 3 5 7 4 - 4

W.S. CENTRAL 166 279 16 10 1,415 433 104 928Ark. 23 19 - - 439 34 3 -La. 28 67 1 2 7 7 - 7Okla. 19 26 - - 66 23 101 56Tex. 96 167 15 8 903 369 - 865

MOUNTAIN 73 83 16 14 739 1,168 258 236Mont. 2 4 - 1 5 30 16 31Idaho 3 7 2 1 62 169 35 28Wyo. - 5 - 1 10 1 18 28Colo. 21 31 2 3 297 256 58 -N. Mex. 4 10 1 2 148 127 7 15Ariz. 23 13 1 1 106 496 108 119Utah 4 7 6 1 68 74 10 14Nev. 16 6 4 4 43 15 6 1

PACIFIC 279 392 74 73 1,041 723 245 315Wash. 53 57 - 1 357 128 - -Oreg. 38 50 N N 166 46 13 3Calif. 177 272 60 34 497 510 208 274Alaska 4 2 - 1 4 9 24 38Hawaii 7 11 14 37 17 30 - -

Guam - - - - - - - -P.R. 5 5 - 1 2 - 49 75V.I. - - - - - - - -Amer. Samoa U U U U U U U UC.N.M.I. - U - U 1 U - U

Vol. 51 / No. 41 MMWR 939



RubellaRocky Mountain CongenitalSpotted Fever Rubella Rubella Salmonellosis


UNITED STATES 763 478 13 20 2 - 30,671 31,343

NEW ENGLAND 3 3 - - - - 1,742 1,989Maine - - - - - - 113 153N.H. - 1 - - - - 113 146Vt. - - - - - - 67 67Mass. - 2 - - - - 969 1,143R.I. 3 - - - - - 129 110Conn. - - - - - - 351 370

MID. ATLANTIC 36 28 1 8 - - 3,799 4,176Upstate N.Y. 7 2 1 1 - - 1,233 949N.Y. City 8 2 - 6 - - 1,061 1,056N.J. 9 7 - 1 - - 562 999Pa. 12 17 - - - - 943 1,172

E.N. CENTRAL 15 15 1 2 - - 4,222 4,104Ohio 10 1 - - - - 1,120 1,080Ind. 2 1 - - - - 372 433Ill. - 12 - 2 - - 1,322 1,173Mich. 3 1 1 - - - 707 714Wis. - - - - - - 701 704

W.N. CENTRAL 93 62 - 3 - - 2,049 1,855Minn. - - - - - - 467 518Iowa 3 2 - 1 - - 390 276Mo. 85 57 - 1 - - 710 491N. Dak. - 1 - - - - 25 54S. Dak. 1 2 - - - - 88 134Nebr. 4 - - - - - 126 134Kans. - - - 1 - - 243 248

S. ATLANTIC 403 230 5 4 - - 8,145 7,134Del. 4 9 - - - - 70 83Md. 46 36 - 1 - - 760 653D.C. - - - - - - 62 68Va. 31 19 - - - - 840 1,105W. Va. 2 - - - - - 106 102N.C. 232 126 - - - - 1,129 1,055S.C. 56 27 - 2 - - 612 672Ga. 21 9 - - - - 1,462 1,370Fla. 11 4 5 1 - - 3,104 2,026

E.S. CENTRAL 88 95 - - 1 - 2,360 2,162Ky. 5 2 - - - - 283 301Tenn. 64 67 - - 1 - 617 517Ala. 16 13 - - - - 658 575Miss. 3 13 - - - - 802 769

W.S. CENTRAL 106 34 2 1 - - 2,504 4,032Ark. 45 5 - - - - 764 735La. - 2 - - - - 516 714Okla. 61 27 - - - - 401 383Tex. - - 2 1 - - 823 2,200

MOUNTAIN 13 10 1 - - - 1,787 1,744Mont. 1 1 - - - - 76 60Idaho - 1 - - - - 116 114Wyo. 4 2 - - - - 58 53Colo. 2 1 - - - - 471 484N. Mex. 1 1 - - - - 251 232Ariz. - - - - - - 492 472Utah - 3 1 - - - 165 184Nev. 5 1 - - - - 158 145

PACIFIC 6 1 3 2 1 - 4,063 4,147Wash. - - - - - - 407 405Oreg. 2 1 - - - - 283 230Calif. 4 - 3 1 - - 3,094 3,184Alaska - - - - - - 50 33Hawaii - - - 1 1 - 229 295

Guam - - - - - - - 19P.R. - - - 3 - - 171 752V.I. - - - - - - - -Amer. Samoa U U U U U U U UC.N.M.I. - U - U - U 25 U




Streptococcal Disease, Streptococcus pneumoniae, Streptococcus pneumoniae,Shigellosis Invasive, Group A Drug Resistant, Invasive Invasive (<5 Years)


UNITED STATES 13,377 14,880 3,319 3,001 1,739 2,147 189 338

NEW ENGLAND 266 257 155 190 17 104 2 36Maine 6 6 20 10 - - - -N.H. 11 6 30 N - - N NVt. 1 7 9 13 4 7 1 -Mass. 166 181 81 57 N N N NR.I. 14 17 15 12 13 4 1 3Conn. 68 40 - 98 - 93 - 33

MID. ATLANTIC 1,041 1,229 547 548 91 138 53 86Upstate N.Y. 229 405 254 223 79 132 53 86N.Y. City 330 344 130 150 U U U UN.J. 302 239 116 110 N N N NPa. 180 241 47 65 12 6 - -

E.N. CENTRAL 1,399 3,548 581 677 180 149 81 98Ohio 520 2,363 184 171 43 - 11 -Ind. 77 178 44 54 132 149 45 47Ill. 535 489 105 219 2 - - 51Mich. 138 255 248 182 3 - N NWis. 129 263 - 51 N N 25 -

W.N. CENTRAL 814 1,450 201 317 170 124 39 52Minn. 177 351 103 141 56 55 39 43Iowa 101 331 - - N N N NMo. 134 268 41 67 5 9 - -N. Dak. 15 20 - 17 1 6 - 9S. Dak. 150 350 12 11 1 3 - -Nebr. 166 67 16 34 29 16 N NKans. 71 63 29 47 78 35 N N

S. ATLANTIC 4,891 2,022 690 492 1,065 1,147 5 5Del. 177 13 2 2 3 6 N NMd. 917 127 117 N N N N ND.C. 48 49 6 21 48 5 1 3Va. 715 260 66 67 N N N NW. Va. 9 8 17 18 37 37 4 2N.C. 313 290 110 125 N N U US.C. 96 221 31 9 153 235 N NGa. 1,234 329 147 156 262 343 N NFla. 1,382 725 194 94 562 521 N N

E.S. CENTRAL 1,069 1,300 90 94 115 205 - -Ky. 119 577 18 34 13 24 N NTenn. 76 79 72 60 102 180 N NAla. 589 182 - - - 1 N NMiss. 285 462 - - - - - -

W.S. CENTRAL 1,156 2,340 106 276 63 242 5 61Ark. 155 494 5 - 6 14 - -La. 299 198 - 1 57 228 2 61Okla. 437 52 38 37 N N 3 -Tex. 265 1,596 63 238 N N - -

MOUNTAIN 683 764 471 337 38 34 4 -Mont. 3 4 - - - - - -Idaho 14 33 9 7 N N N NWyo. 8 7 7 11 9 5 - -Colo. 144 196 120 130 - - - -N. Mex. 138 107 89 68 29 27 - -Ariz. 307 300 217 118 - - N NUtah 28 49 29 3 - - 4 -Nev. 41 68 - - - 2 - -

PACIFIC 2,058 1,970 478 70 - 4 - -Wash. 129 159 65 - - - N NOreg. 83 92 N N N N N NCalif. 1,789 1,662 351 - N N N NAlaska 6 6 - - - - N NHawaii 51 51 62 70 - 4 - -

Guam - 37 - 1 - - - -P.R. 7 15 N N - - N NV.I. - - - - - - - -Amer. Samoa U U U U - - U UC.N.M.I. 17 U - U - - - U

Vol. 51 / No. 41 MMWR 941



Syphilis TyphoidPrimary & Secondary Congenital Tuberculosis FeverCum. Cum. Cum. Cum. Cum. Cum. Cum. Cum.

Reporting Area 2002 2001 2002 2001 2002 2001 2002 2001UNITED STATES 4,848 4,700 250 401 9,110 10,727 201 285

NEW ENGLAND 111 47 - 4 277 354 15 13Maine 2 - - - 10 15 - 1N.H. 4 1 - - 10 13 - 2Vt. 1 2 - - - 4 - -Mass. 78 26 - 3 155 184 9 9R.I. 6 8 - - 29 49 - -Conn. 20 10 - 1 73 89 6 1

MID. ATLANTIC 545 406 45 64 1,651 1,793 46 99Upstate N.Y. 26 15 5 4 227 276 8 15N.Y. City 330 221 19 30 845 892 23 41N.J. 114 101 20 30 395 395 11 36Pa. 75 69 1 - 184 230 4 7

E.N. CENTRAL 845 819 37 55 946 1,094 18 31Ohio 122 65 2 2 151 215 6 3Ind. 57 129 - 8 88 77 2 2Ill. 256 287 26 36 469 513 1 17Mich. 391 316 9 5 197 227 4 5Wis. 19 22 - 4 41 62 5 4

W.N. CENTRAL 80 82 - 9 425 424 8 13Minn. 38 30 - 2 179 174 3 6Iowa 2 4 - - 24 34 - -Mo. 22 22 - 5 110 109 1 7N. Dak. - - - - 1 3 - -S. Dak. - - - - 9 12 - -Nebr. 3 7 - - 20 29 4 -Kans. 15 19 - 2 82 63 - -

S. ATLANTIC 1,255 1,614 62 98 1,787 1,982 32 35Del. 10 11 - - 13 15 - -Md. 149 203 13 3 222 174 7 9D.C. 48 32 1 2 - 51 - -Va. 51 83 1 4 145 198 1 10W. Va. 2 3 - - 27 25 - -N.C. 228 375 18 12 275 267 1 2S.C. 98 199 7 20 141 143 - -Ga. 271 310 8 22 313 361 8 9Fla. 398 398 14 35 651 748 15 5

E.S. CENTRAL 381 512 12 27 574 655 4 1Ky. 77 38 3 - 105 102 4 -Tenn. 139 263 3 16 228 240 - 1Ala. 131 95 4 5 161 211 - -Miss. 34 116 2 6 80 102 - -

W.S. CENTRAL 656 573 53 66 1,330 1,628 4 15Ark. 25 30 2 6 101 119 - -La. 121 134 - - - 100 - -Okla. 51 50 3 5 111 119 - -Tex. 459 359 48 55 1,118 1,290 4 15

MOUNTAIN 223 175 12 26 274 426 10 8Mont. - - - - 6 6 - 1Idaho 1 1 - - 9 7 - -Wyo. - 1 - - 3 3 - -Colo. 33 20 1 1 48 103 5 1N. Mex. 26 15 - 2 21 45 1 -Ariz. 150 124 11 23 150 168 - 1Utah 6 8 - - 24 29 2 1Nev. 7 6 - - 13 65 2 4

PACIFIC 752 472 29 52 1,846 2,371 64 70Wash. 48 41 1 - 180 189 4 4Oreg. 14 13 1 - 86 84 2 7Calif. 682 407 26 52 1,423 1,945 54 56Alaska - - - - 40 40 - 1Hawaii 8 11 1 - 117 113 4 2

Guam - 5 - 1 - 47 - 2P.R. 199 209 13 9 33 95 - -V.I. 1 - - - - - - -Amer. Samoa U U U U U U U UC.N.M.I. 15 U - U 32 U - U


U: Unavailable. -:No reported cases.* Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. A death is reported by the place of its

occurrence and by the week that the death certificate was filed. Fetal deaths are not included.† Pneumonia and influenza.§ Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks.¶ Total includes unknown ages.

TABLE III. Deaths in 122 U.S. cities,* week ending October 12, 2002 (41st Week)All Causes, By Age (Years) All Causes, By Age (Years)

All P&I† All P&I†

Reporting Area Ages >65 45-64 25-44 1-24 <1 Total Reporting Area Ages >65 45-64 25-44 1-24 <1 Total

NEW ENGLAND 489 336 108 31 8 5 46Boston, Mass. 152 97 40 8 5 1 13Bridgeport, Conn. 30 22 5 3 - - -Cambridge, Mass. 18 16 - 1 1 - 2Fall River, Mass. 17 14 3 - - - 4Hartford, Conn. 50 26 16 7 1 - 1Lowell, Mass. 25 20 5 - - - 3Lynn, Mass. 14 10 4 - - - 1New Bedford, Mass. 25 18 7 - - - 3New Haven, Conn. 32 23 8 1 - - 3Providence, R.I. U U U U U U USomerville, Mass. 6 3 2 1 - - -Springfield, Mass. 36 23 6 3 1 3 4Waterbury, Conn. 36 29 3 4 - - 6Worcester, Mass. 48 35 9 3 - 1 6

MID. ATLANTIC 1,831 1,286 370 113 40 22 82Albany, N.Y. 59 46 9 3 - 1 4Allentown, Pa. 18 16 2 - - - -Buffalo, N.Y. 56 42 11 1 1 1 7Camden, N.J. 22 16 3 2 1 - 3Elizabeth, N.J. 16 14 2 - - - -Erie, Pa. 34 24 6 2 2 - 3Jersey City, N.J. 34 26 5 3 - - -New York City, N.Y. 1,049 755 209 59 19 7 37Newark, N.J. 42 22 12 6 2 - 2Paterson, N.J. 17 7 7 1 - 2 1Philadelphia, Pa. 253 147 66 26 9 5 8Pittsburgh, Pa.§ 15 9 5 1 - - -Reading, Pa. 20 16 3 1 - - 3Rochester, N.Y. U U U U U U USchenectady, N.Y. 27 20 5 1 1 - 3Scranton, Pa. 31 23 6 - 2 - 1Syracuse, N.Y. 99 74 14 4 2 5 7Trenton, N.J. 17 13 3 - - 1 1Utica, N.Y. 22 16 2 3 1 - 2Yonkers, N.Y. U U U U U U U

E.N. CENTRAL 1,585 1,064 313 101 48 59 95Akron, Ohio 51 31 8 6 1 5 1Canton, Ohio 40 29 7 - 3 1 4Chicago, Ill. U U U U U U UCincinnati, Ohio 71 49 14 4 2 2 10Cleveland, Ohio 154 97 37 12 1 7 4Columbus, Ohio 188 128 34 15 7 4 10Dayton, Ohio 136 96 28 6 4 2 11Detroit, Mich. 182 99 49 13 6 15 12Evansville, Ind. 34 30 3 - - 1 -Fort Wayne, Ind. 72 47 16 4 4 1 2Gary, Ind. 16 10 3 2 1 - -Grand Rapids, Mich. 39 33 3 2 1 - 7Indianapolis, Ind. 183 114 39 13 7 10 16Lansing, Mich. 49 38 7 - 1 3 2Milwaukee, Wis. 115 71 25 11 4 4 6Peoria, Ill. 39 31 4 - 1 3 4Rockford, Ill. 44 36 6 - 2 - 3South Bend, Ind. 31 25 3 3 - - 2Toledo, Ohio 79 57 14 5 2 1 -Youngstown, Ohio 62 43 13 5 1 - 1

W.N. CENTRAL 544 373 100 36 22 13 42Des Moines, Iowa 57 43 8 3 1 2 4Duluth, Minn. 38 30 4 2 - 2 5Kansas City, Kans. 26 19 4 3 - - 1Kansas City, Mo. 86 47 23 10 4 2 3Lincoln, Nebr. 45 31 11 - 3 - 4Minneapolis, Minn. 80 49 16 5 5 5 4Omaha, Nebr. 82 66 10 3 2 1 16St. Louis, Mo. U U U U U U USt. Paul, Minn. 50 38 8 3 1 - 4Wichita, Kans. 80 50 16 7 6 1 1

S. ATLANTIC 1,269 768 296 114 46 42 65Atlanta, Ga. 140 71 42 19 7 1 6Baltimore, Md. 150 90 40 11 5 4 13Charlotte, N.C. 125 90 18 12 2 3 11Jacksonville, Fla. 143 93 31 11 3 5 8Miami, Fla. 45 29 10 5 - 1 3Norfolk, Va. 46 26 7 4 6 3 1Richmond, Va. 57 28 20 6 2 1 3Savannah, Ga. U U U U U U USt. Petersburg, Fla. 67 45 12 4 3 3 1Tampa, Fla. 186 122 40 14 1 9 12Washington, D.C. 299 167 72 28 17 12 4Wilmington, Del. 11 7 4 - - - 3

E.S. CENTRAL 669 464 131 45 18 11 57Birmingham, Ala. 144 101 28 6 5 4 14Chattanooga, Tenn. 86 55 18 6 5 2 6Knoxville, Tenn. 91 68 15 6 2 - 8Lexington, Ky. 77 53 17 5 1 1 3Memphis, Tenn. U U U U U U UMobile, Ala. 71 49 16 4 1 1 2Montgomery, Ala. 42 31 7 2 2 - 9Nashville, Tenn. 158 107 30 16 2 3 15

W.S. CENTRAL 1,443 893 320 119 56 55 88Austin, Tex. 76 41 18 6 9 2 3Baton Rouge, La. 72 38 22 11 1 - 1Corpus Christi, Tex. 50 36 8 2 2 2 3Dallas, Tex. 181 102 44 16 8 11 13El Paso, Tex. 79 53 18 7 1 - 2Ft. Worth, Tex. 121 79 26 6 5 5 10Houston, Tex. 352 203 82 39 11 17 30Little Rock, Ark. 68 38 17 3 5 5 -New Orleans, La. U U U U U U USan Antonio, Tex. 203 145 34 14 5 5 12Shreveport, La. 91 65 16 3 2 5 9Tulsa, Okla. 150 93 35 12 7 3 5

MOUNTAIN 833 594 158 48 16 17 59Albuquerque, N.M. 120 83 25 6 4 2 8Boise, Idaho 39 25 10 2 2 - -Colo. Springs, Colo. 51 41 5 1 2 2 5Denver, Colo. 85 59 14 6 4 2 3Las Vegas, Nev. 210 135 55 14 1 5 15Ogden, Utah 29 23 5 1 - - 2Phoenix, Ariz. U U U U U U UPueblo, Colo. 28 19 8 1 - - -Salt Lake City, Utah 142 108 22 8 3 1 15Tucson, Ariz. 129 101 14 9 - 5 11

PACIFIC 1,597 1,116 302 120 34 25 87Berkeley, Calif. 16 13 1 1 - 1 -Fresno, Calif. 79 59 15 2 3 - 7Glendale, Calif. 13 10 1 2 - - -Honolulu, Hawaii 79 56 13 2 5 3 1Long Beach, Calif. 65 41 16 6 1 1 8Los Angeles, Calif. 411 295 68 34 10 4 -Pasadena, Calif. 18 11 4 2 - 1 3Portland, Oreg. 91 63 18 7 2 1 6Sacramento, Calif. 170 115 38 10 5 2 17San Diego, Calif. 163 112 34 11 2 4 13San Francisco, Calif. U U U U U U USan Jose, Calif. 184 128 31 18 3 4 19Santa Cruz, Calif. 34 24 8 2 - - 3Seattle, Wash. 110 73 23 13 1 - 3Spokane, Wash. 49 34 9 3 1 2 3Tacoma, Wash. 115 82 23 7 1 2 4

TOTAL 10,260¶ 6,894 2,098 727 288 249 621

Vol. 51 / No. 41 MMWR 943

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